Presentation on theme: "COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE"— Presentation transcript:
1 COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE National Drug Treatment Centre Board ConferenceDublin, November 16/17th, 2006Dr. Gerry McCarney
2 Complex needs of young drug users and our treatment response A look at the needs of young peopleDrug use in adolescenceWhy treat now?Principles of development and deliveryHow we are responding to this need in an Irish context – service modelSpecial needs / vulnerable groups
3 review of early clients 86 consecutive clients, 54/46 - female : maleAdolescent age range 14-18, mean 16.8 yrsDrug history -Opiate users +/- other drug use1st drug use age 12 , 14.7Daily opiate use 12/12Polydrug use 60%, inc. street methadone (78%)IVDA hx. 59% (33% currently), 64% not testedStudy carried out by Dr.John Fagan et al-Fagan, Smyth & Naughton.
4 YPP- study findings cont’d 58% living with parents30% homeless!(half in hostels)9% partner48% had been homeless27% in care before51% has SW inputLeft boys earlier14% expelled, 50% dropped out37% had work history
5 YPP- study findings52% in relationship, 45% overall had a heroin using partner45% hx. sibling opiate, 58% parental EtOH48% convicted, 31% prison, 38% charges52% saw psych., 11% admitted, 33% DSHBOYS earlier to leave school, use heroin, be in care,+ family hx.GIRLS-more likely to have relationship with user
6 What this says.. attendees at YPP exhibit a history of: Early drug use progressing to daily useHave early care disruption/chaos+ family history of substance misuseUse many drugs, many IVDA not testedSignificant forensic involvementSignificant co-morbidityMulti agency integration approach required
7 Maslow’s Hierarchy of Need Help me , I cannot stop using!Every Child Matters 2004 – 5 outcomes mirror Maslow- being healthy, staying safe, enjoying & achieving, making a positive contribution, economic wellbeing. Norwood- coping information, rest left unattended. Then helping information, etc, enlightening, empowering , and so on.Level 1- breathe, eat, sleep. 2- safety, health, belongings. 3- friendship, sexual intimacy, communication. 4- self respect, respect from others, confidence, competence.The ‘need’ to use drugs can override all of the above
8 Needs of young drug misusers Physical- shelter, food, clothes,Safety- from adults, peers, society, drugsBelonging- need for love-family attachment, communication, contact from others, non-judgemental care,Self-esteem- esteem, self concept, negative self view, anxiety, depressionAutonomy- still dependent -on whom?Self actualisation- SUD can delay developmental process
9 Why people use drugsReasons- curiosity, media, pos reinforcement, enhance sensations, increase psychophysical performance, social pressure, peer association & youth culture,After first try, other times may be a lot easier- pos reinforcemnetDrug use may be statistical ‘normal’ in some micro-communities‘normalised’ in peer group-access & acceptableCannabis ‘not a drug’ view- denial of riskSocial acceptance of cocaine use increasedTrans-generational SUD- heroin even!Adolescent factors- Bobby has covered
10 Why treat?‘Normal for adolescents’?- rebellion, peer involvement, individuating, experimentation- BUT….adult addiction starts in adolescence.SUD has ‘epidemic character’ in adolescenceCritical time – development, social & emotional learning, education & employment.Co-morbidity , psychosocial damage, criminality, trans-generational prevention.What can we prevent now- (Harrison 2001) – while ¼ remain clean, Rx does reduce overall use, symptoms, criminality, emotional distress
11 More reasons to treat!COST-EFFECTIVE- Godfrey UK study- for every £1 invested in Rx, save between £9-18. Looked at settings from Tier 1 to Tier 4.Keating- $7 return for every $1 spent.Crime- proposed link to 29% drop in crime in Dublin area due to increased MMTHospital visits- alcohol, heroin, prescription drugs, injury, overdose- heroin related to more ‘all cause’ visits over time ( Tait 2002)Keating D, Hertzmann C, (1999) – developmental health and the wealth of Nations. Social, Biological and Educational Dynamics.New York- Guildford press. $7 return for every $1 spent- greatest return when spent in most deprived sectors of the population.
12 Treatment needs of young people Needs may pre-date, worsen with or be a consequence of drug use.CRAVINGS, VIRAL STATUS, OVERDOSE RISK,ABCSCESSES, TRAUMA, DEPRESSION, ANXIETY,ADHDbiologicalHUNGERCOLDCOPING /LIFE SKILLS, DEPRESSION, ANXIETY,SELF HARM,PSYCHOSIS,MOTIVATION , TRAUMA,ANGER, CONCENTRATIONEMOTIONAL DYSREGULATIONACCOMODATION, BENEFITS,FAMILY ACCESS,DOMESTIC VIOLENCE,LEGAL ISSUES, EMPLOYMENT,SCHOOL, SEXUALITYsocialpsychological
13 Response to treatment needs medical /surgical Rx/ MedicationSubstitution RxNeedle exchangeViral ScreeningMULTI-AGENCYPARTNERSHIPWORKINGbiologicalScreening & educationFunctional analysisCounsellingBrief MICBTFamily therapyYoung PersonLiaison with SW, probation, childcare, family, contraceptive advicepsychologicalsocialInformation
14 Service developmentCore aspiration- young people will use us! i.e., engagement & retentionCurrent best practice, evidence based, accessible.Respect dignity, ethnicity, language, culture.Non-complex presentation of information .Information- how to get help, drugs, feelings, sexual matters, day activities, training, family.Policies & rules-client & staff safety, legal framework- police, probation, courts.Confidentiality- not absolute-child protection.Transitional care plan for before their eighteenth birthday.
15 Service deliveryListen to what young people tell us- try to develop services that they will engage with.Careful common assessment, information sharing, multi-agency working. Multi-system interventionIncrease accessibility- self help programmes, drop in centres, OP access, day Rx centres.Information based intervention is suitable for Tier 1. Peer support and advice. Can be delivered in schools and youth groups also.Support & education for Tier 1 & 2 from Tier 3. Referral pathways clarified.NEED TO INVOLVE FAMILY IF POSSIBLE.Reform delivery & strengthen accountability-prevention & early intervention-drug misuse assessments to be part of all services- build service & workforce capacity. NTA Essential Elements document June 2005.
16 4 TIER MODELTier 1- No specialist skills in either adolescent MH or Addiction. Any professional working with young person.Tier 2- specialist skills in one of addiction or adolescentTier 3- specialist skills in both areas. New developing service.Tier 4- specialist skills in both, and an inpatient / day hospital service.HAS integrated care pathways- common assessment framework & avoid duplication- information sharing, multi-agency partnership working. Will develop KPI’s and aim to prioritise high risk / vulnerable groups. Mainstream services should remain in contact and often be the co-ordinators.
17 4 TIER MODEL CAMH-child & adolescent mental health/ CAA- child & adol 4 TIER MODEL CAMH-child & adolescent mental health/ CAA- child & adol. addictionTier levelSpecialist skills available to help young drug usersType of adolescent accessing serviceType of intervention for drug useIntervention delivered byExamples of such servicesIntensity and durationNOT either CAMH or CAAStart of drug useBasic advice +/- referralIndividual professionalTeacher, SW, GP, A&E, POLow intensity-ongoingEither CAMH or CAAProblems due to drug useBasic counselling, brief intervention, harm reductionIndividual or MDTCAMHS, Addiction DTF,Medium intensity-Medium durationBoth CAMH & CAA based in the communitySubstantial problems due to drug useSpecialist counselling, family therapy, medicationSpecialist MDT in adolescent addictionSpecialist adolescent addiction serviceHi- intensity,Short / medium/ long termCAMH & CAA at In-Patient / Day hospitalSevere problems or drug dependenceIndividual & family therapy medication, residential- detox / stabilisespecialist MDT in adolescent addictionSpecialist day hospital or in-patient adol. AddictionVery high intensity ,Short/medium/ long termTier 1Tier 2Multi-agency working. Clear guidelines and role definitions. YOT, CAMHS, Looked after children- responsibilities remain, but greater wrap around care possible. Secondment a good learning opportunity. Tier 1-To ensure universal access, continuity of care. Identify those at risk. Tier2- reduce risks, reintegrate. Tier 3- deal with complex and multiple needs, reintegrate. Tier 4- for high intensity for high risk- medication, residential, MDT daily access.Tier 3Tier 4
18 Tier 4 service thus far..Tier 4 team – Project manager, key workers, nurses, counsellors, family therapist, SW, psychologist, doctors.Complementary- Artwork, Reiki, MusicToken economy, card system, contingency mx, careplanning, case review, keyworker.Offer intensive day hospital /residential.
19 ROLE OF KEYWORKER ‘The link’ between young person & service Co-ordinator / advocate / educator / identifier of resources / engagerFrequent positive contact & supportMonitor drug use & progressFacilitate engagement with family & teamLimited outreach capacityContact, connection, care.
20 Tier 3,2,1 serviceMDT Tier 3- two being developed in the community in Dublin.Multidisciplinary- core competency mixLocal accessibility and integrationAdaptable- offer brief early interventionEducation and advice supportive roleMulti-agency Tiers 1 & 2- some already in place, others in need of development.
23 How do we approach a session? Each is still a young person, and deserves culturally appropriate respect as a person. Generally, the process is as for any other.Ensure the reason for and process of the assessment are explained.Drug issues need not be the first topic.If intoxicated, can ask advice of a colleague.If threatening, ask advice of colleague, and do not continue session. This is not common!Make the YP feel ‘it is about you & for you’.Capitalise on existing relationships, understanding the young person & continuing interpersonal relationships will strengthen care pathways. Holistic assessment. Joint assessment. Invite family, invite other agencies if appropriate, but make the YP feel that you listen to Him/Her !
24 Questions to ask re: drug use Age at first use?Which drugs triedWhen started using on daily basisMethod of taking – po, intranasal, IVDAWeekly /daily patternGo thro’ each drugWhat it does for you?How much it costsHow they pay for itKnowledge re: risks of drug use- effects of drugs, IVDA risk, sexualForensic historyEffect on friends & familyFamily history-context
25 Symptoms and ASUD Paranoid thoughts Delusions Hallucinations Thought disorderConcentrationMotivationBehaviour changeSpeech, affectDepression / ManiaAnxietyRestlessnessAppetite, energySkin, nose, eyesUnexplained weight lossSelf care, strange
26 Co-morbidity/ dual diagnosis More violence, suicidal behaviour, service costs and poor Rx outcome in both populations.Increased threshold for entry to both services.2003-UK. CMHT- 44% reported drug/harmful alcohol use. (adult)In addiction services- anxiety & depression both near 30%.Personality disorders common. Psychosis 10%.Poor coping, relationship problems, hopeless.DD-adolescent- 31% had psych.visit – 54% with prior Dx visited- girls & internalisers more likely -Sterling SF 2005High rates of depression, anxiety, eating dis, ADHD, CD.
27 Early age alcohol consumption Adolescent alcohol- 1% A/E admissions, 50% trauma admissions for that age groupUnderage drinking in unsupervised locationsAggression, violence, accidents and traumaRoad traffic accidents- young men especially.DSH, depression, anxiety, PTSD , ADHD(CD).Alcohol problems are more predictive of suicidal behaviour in males.
28 Sexual risks Early menarche- more smoking & drinking Disinhibition, reduced recall and self-awarenessSex for drugs, sex workSTIs and early pregnancySexual / contraception knowledgeCondom negotiation skills
29 Profile of Pregnant Drug User Single & PoorUnemployedUnskilledLack child care facilitiesSuffered traumaPoor parenting skills or confidenceIncreased stigma when pregnantFear / suspicion of servicesPoor nutrition & dental careInfectious disease risk50% have partner using
30 Treatment Aims (Day, 2003) Practical & emotional support offered Ante- and post-natal use of multiple services- obstetric, medical, addiction, SS.Early booking appt. ensures safety & allows education re: care and benefitsPromotion of child welfarePeriod of engagement is for duration of pregnancy and beyond, including advice re: family planning.
31 Forensic associationCrime association- may share same risk factors only.predictive dose-response relationships in both directions.Violence, vandalism, fraud ~ adolescent drug useTheft not only assoc. with drug use. Peer behaviour & prior forensic hx also determine crime (Hammersley).Criminality reduces after residential Rx.High rate of SUD in prison population- all should be screened-Audit Commision UK & othersPolydrug use ~90% boys .Studies- Howard 1990, Pottieger 1991, Hagell 1994, Misspent youth (audit commission 1996), Williamson 1996, Collinson ’94,’96- all found high drug use – most in the 90% reange, and mostly polydrug use. Boys more than girls, - crime & drug use studied by Hammersley in Scotland &
32 Drug offence prosecutions for U-17s by gender, 1995-2004.
33 Homeless – vicious cycle Family breakdown & drug / alcohol use.SUD can exclude from a/c- many youngPredictors- peer & family drug use & attitudes, psychological well-beingVery difficult to engage- often hx of careSafety- violence, sexual violence, adult manipulation, criminalityTreatment access after leaving prison
34 Early School- leaving Many leave school early- < 14. Link in with delinquent peer group.1/10 no qualifications, 1/5 no Leaving Cert.Effects of drug use- poor school performance, lose positive peer group and social skills enhancement.ESPAD figures. Comiskey & Miller 2000.Polydrug use.
35 Adolescent drug users - different from adults at presentation Less dependence evidentBinge pattern more commonIntoxication effects prominentOften reluctant patients, hence ENGAGEMENT a big issue- this can be over months.Peer influence greater- family support vital.Rehabilitation- creative thinking required.Harm reduction is the overall aim- includes abstinence & stabilisation.
36 THANK YOU!Un Convention on the Rights of the Child Article 33 of UN CRC –‘States parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.’